HIPPA Notice of Privacy Practices

HIPPA Notice of Privacy Practices
Upon completion of this form, you will receive our HIPPA Privacy Practices. We are required to provide you an opportunity to review this document.
Patient Name*

First NameLast Name
Patient DOB:*

MonthDayYear
Date
Patient Signature (or Guardian if patient is a minor)*

Clear
Guardian Name, if patient is a minor

First NameLast Name
Today's Date*

MonthDayYear
Date
Patient Email (or Guardian, if patient is a minor)*
example@example.com
Should be Empty: